Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

Latar Belakang Keselamatan pasien (patient safety) rumah sakit adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman yang meliputi assessment risiko, identifikasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden, kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi solusi untuk meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak mengambil tindakan yang seharusnya diambil yang dilakukan oleh perawat (Kemenkes, 2011).Salah satu kesalahan yang dapat merugikan pasien adalah medication error. Menurut WHO (2016) medication error adalah setiap kejadian yang dapat dicegah yang menyebabkan penggunaan obat yang tidak tepat yang menyebabkan bahaya kepasien, dimana obat berada dalam kendali profesional perawatan kesehatan. proses terjadi medication error dimulai dari tahap prescribing, transcribing, dispensing,dan administration. Kesalahan peresepan (prescribing error), kesalahan penerjemahan resep (transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan obat kepada pasien (administration error). Medication error yang paling sering terjadi adalah pada fase administration / pemberian obat yang dilakukan oleh perawat.Administration error terjadi ketika pemberian obat kepada pasien tidak sesuai dengan prinsip enam benar yaitu benar obat, benar pasien, benar dosis, benar rute pemberian, benar waktu pemberian dan benar pendokumentasian. Secara global, kesalahan pemberian obat (medication errors) sampai saat ini masih menjadi isu keselamatan pasien dan kualitas pelayanan di beberapa rumah sakit (Depkes RI, 2015; AHRQ, 2015). Perawat sebagai bagian terbesar dari tenaga kesehatan di rumah sakit, mempunyai peranan dalam kejadian medication error. Perawat berkontribusi karena perawat banyak berperan dalam proses pemberian obat. Pemberian obat/ Medication Administration adalah salah satu intervensi keperawatan yang paling banyak dilakukan, dengan sekitar 5- 20% waktu perawat dialokasikan untuk kegiatan ini (Härkänen et al.,, 2019). Pemberian obat juga mencakup tugas-tugas lain, seperti menyiapkan dan memeriksa obat obatan, memantau efek obat-obatan, mengedukasi pasien tentang pengobatan, dan memperdalam pengetahuan perawat tentang obat – obatan sendiri (DrachZahavy et al., 2014 dalam Yulianti et al., 2019)Berdasarkan isu tersebut, penulis tertarik untuk melakukan literature review terkait faktor perawat dalam pelaksanakan keselamatan pasien terhadap kejadian medication administration error di Rumah Sakit.

scholarly journals Literature Review: Cause Factor Analysis and an Effort to prevent Medication Administration Error (MAE) at Hospital

2020 ◽  
Vol 9 (2) ◽  
pp. 98-107
Author(s):  
Innes Rizma Brigitta ◽  
Inge Dhamanti
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Preventive Measures ◽  
Health Workers ◽  
Medication Administration ◽  
Literature Study ◽  
Safety Standards ◽  
Medication Administration Error ◽  
Safety Incident ◽  
Administration Error

The high number of medical errors, especially in medication administration errors (MAE) in the last few decades that have occurred in hospitals in developed and developing countries makes patient safety an important issue. This requires the hospital to take steps that prioritize patient safety by focusing on preventive measures, so as to reduce the risk of an MAE. The writing of this article of literature review aims to explain the determinants of MAE in hospitals and their prevention efforts through preventive measures, so that patient safety standards in hospitals (zero defects) can be achieved. The design of the article search in this literature study was carried out through Google scholar, JAKI, and PSNet with the keywords of patient safety incident, medication administration error, contributing factor of MAEs, and determinant factor of MAEs. Based on 13 articles that have been obtained in accordance with the criteria, there are 38 determinant factors in MAE which are grouped into three categories, namely ineffective communication factors, work environment factors, and human factors. Various preventive efforts that can be done to prevent MAEs include: implementing crew resource management, clarifying the chain of command, using the communication form of SBAR, designing an ergonomic workplace, implementing Patient Advocacy Reporting System (PARS), providing training and education for health workers, and setting work schedules that do not exceed workload. Implementation of effective MAE preventive measures can reduce the number of MAEs in the hospital directly.

scholarly journals FAKTOR PERAWAT TERHADAP KEJADIAN MEDICATION ADMINISTRATION ERROR DI INSTALASI RAWAT INAP

2017 ◽  
Vol 5 (1) ◽  
pp. 52
Author(s):  
Vidia Sabrina Budihardjo
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Inpatient Ward ◽  
Medication Incident ◽  
Medication Administration Error ◽  
Administration Error ◽  
Initial Survey ◽  
Service Standards ◽  
Observational Descriptive Study

Medication administration error is one of medication error that happened due to unfulfillment of drug instruction or drug administration that is different with the recipe. From the initial survey conducted in 2015, there were 13 events medication errors known in 2014-2015 in RSU Haji Surabaya. Based on Kepmenkes RI nomor 129/Menkes/SK/II/2008 about Minimum Service Standards, medication incident should not be any error occurred in the Hospital.This study was an observational descriptive study aimed to identify factors that contribute to the incidence of medication errors. Respondents were 56 nurses that worked on 7 inpatient wards. Variablesi n this research  are: the skills of nurses, nurse's knowledge, and communication between nurse and patients. The result showed that the incidence of medication error in 2014-2016 amounted to 14 events that occurred in most of the inpatient ward (57.1%). Most of inpatient ward  (57.41%) had good skill of nurses, most of the inpatient wards (57.1%) had a sufficient knowledge and communication of nurses.From this study it can be concluded that the skills of nurses, nurse's knowledge, communication between nurse and patients are contributing to the incidence of medication errors in RSU Haji Surabaya. Keywords: inpatient ward, medication errors, nurses

scholarly journals THE IMPACT OF BARCODE MEDICATION ADMINISTRATION ON PATIENT SAFETY: A SYSTEMATIC REVIEW

2021 ◽  
Vol 5 (6) ◽  
Author(s):  
Seham Sahal Aloufi
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Medication Error ◽  
Medication Errors ◽  
Improve Patient Safety ◽  
Hospital Setting ◽  
Medication Administration ◽  
Bar Code ◽  
The Impact ◽  
Improve Patient

Patient safety is considered as an essential feature of healthcare system. Many trials have been conducted in order to find ways to improve patient safety, and many reports indicate that medication errors pose a threat to patient safety. Thus, some studies have investigated the impact of bar code medication administration (BCMA) system on medication error reduction during the medication administration procedure. This systematic review (SR) reports the impact of BCMA system on reducing medication errors to improve patient safety; it also compares traditional medication administration with the BCMA system. The review concentrates on the effectiveness of BCMA technology on medication administration errors, and on the accuracy of medication administration. This review also focused on different designs of quantitative studies, as they are more effective at investigating the impact of the intervention than qualitative studies. The findings from this systematic review show various results depending on the nature of the hospital setting. Most of the studies agree that the BCMA system enhances compliance with the 'five rights’' requirement (right drug, right patient, right dose, right time and right route) of medication administration. In addition, BCMA technology identified medication error types that could not be identified with the traditional approach which is applying the 'five rights' of medication administration. The findings of this systematic review also confirm the impact of BCMA system in reducing medication error, preventing adverse events and increasing the accuracy of the medication administration rate. However, BCMA technology did not consistently reduce the overall errors of medication administration. Keyword: Patient Safety, Impact, BCMA, eMAR

A Review of Ergonomics and Simulation Modeling in Healthcare Delivery System

2013 ◽  
Vol 845 ◽  
pp. 604-608 ◽  
Author(s):  
Ali Anjomshoae ◽  
Adnan Hassan ◽  
Mat Rebi Abdul Rani
Keyword(s):  
Patient Safety ◽  
Delivery System ◽  
Simulation Modeling ◽  
Clinical Performance ◽  
Healthcare Delivery ◽  
Medication Administration ◽  
High Rate ◽  
Healthcare Delivery System ◽  
Medication Administration Error ◽  
Administration Error

This paper is an overview of recent issues in determining healthcare delivery systems and aims to explain how Human Factor and Ergonomics (HFE) and simulation modeling can contribute to the quality of patient safety and healthcare delivery. It has been found that the layout of the patient unit and resources are significant factors that influence the amount of medication errors and therefore should be included in any description of the research context. Therefore current trends and applications of HFE as well as simulation modeling and how they can contribute to provide safe, efficient, and effective service to the patients are discussed. This review provides previous work of researchers to identify relationships between these two areas of research, particularly in patient safety. The review suggests that, high rate of medication administration error is due to inefficient healthcare delivery system and highlights the efficiency of simulation modeling versus ergonomics in analyzing the root cause of problems in clinical performance.

scholarly journals Magnitude of Medication Administration Error and Associated Factors Among Nurses Working in Madda Walabu University Goba Referral Hospital, Bale Zone Oromia Region, Southeast Ethiopia

2020 ◽  
Author(s):  
Hiwot Fikadu Haile ◽  
Abulie Melku Takele ◽  
Addisu Gemechu Abdi
Keyword(s):  
Medication Error ◽  
Drug Administration ◽  
Work Experience ◽  
Associated Factors ◽  
Medication Administration ◽  
Referral Hospital ◽  
P Value ◽  
Medication Administration Error ◽  
Administration Error ◽  
Bale Zone

Abstract Background: Administration of medication is the primary responsibility of nurses. Medication errors occurring during the drug administration process can be attributed to a variety of safety effects, ranging from undetected errors to prolonged hospital stays, discomfort and death.Objective: To determine the magnitude of the medication administration error and associated factors among nurses working at Madda Walabu University Goba Referral Hospital, Bale Zone Oromia Region, South East Ethiopia.Methods: A facility-based cross-sectional study was conducted at Madda Walabu University Goba Referral Hospital Inpatient Department from February to March, 2020. The study included three hundred ninety-eight medication interventions administered by 89 inpatient unit working nurses during the study period. Data were collected using a pre-tested, structured questionnaire and drug administration assessment using a checklist. Data were analyzed using SPSS version 22 and Frequency , Percentage, Means and SD were analyzed for descriptive analysis. COR and AOR were calculated to see the association of independent variables and uncontrolled hypertension at 95% CI and p-value <0.05 was considered statistically significant.Result: The magnitude of the medication error was 248 (62.3%). The most common type of medication error was wrong documentary evidence (53.5% ) , followed by wrong time (39.2%) and wrong dosage (28.%). Variables that were substantially associated with medication administration error include work experience of nurses 0-4 years (AOR = 10.8, 95% CI (4.5-25.86), 5-9 years of service (AOR = 4.05, 95% CI (1.47-11.715), nurses 1-6 (AOR = 0.36, 95% CI (0.17-0.76) nurses 7-10 (AOR = 0.45, 95%CI (0.21-0.96) route IV of medication (AOR =0.13, 95 % CI (0.03 - 0.60) and IM route (AOR =.0.12, 95 % CI (0.02 -0.74) at p-value <0.05. Conclusion: Medication administration error was highly prevalent. Work experience, nurse to patient ratio and route of medication administration were statistically significant factors associated with occurrence of medication administration error. The preparation of nurses and the hospital staff profile would be helpful in minimizing mistakes in the administration of drugs.

scholarly journals Root Cause Analysis of Medication Administration Error by Nursing Staff at a Number of Medical Institutes in Riyadh

2021 ◽  
pp. 152-161
Author(s):  
Tahani Alrahbeni ◽  
Muteeb Eid Alenezi
Keyword(s):  
Medication Errors ◽  
Clinical Pharmacist ◽  
Medication Administration ◽  
Cross Sectional Study ◽  
Ministry Of Health ◽  
Target Number ◽  
Cross Sectional ◽  
Medication Administration Error ◽  
Administration Error ◽  
The Times

Background: Medication errors genuinely influence patient safety, staying cost in hospital and integrity of nursing job, because the nurses play a specific part in managing the medication for the patients. The present study was done with the aim to investigate factors associated with nurses’ medication errors in a number of medical institutes (Ministry of Health) and the role of clinical pharmacist in these errors. Methodology: The present study was a cross-sectional study based on standardized questionnaire which was designed and distributed to the target nurses in a number of medical institutes (Ministry of Health). The target number was (171) which was achieved depending on the calculation of sample size after the questionnaires was gathered; data was subjected to descriptive and inferential statistics. Results: The highest mean score of error was obtained in the factor related to medication packaging reason, which includes that different medications look alike, and the names of at least 60 medications were similar by 82.7%.  The second group of reasons was system associated, which included: abbreviations were used instead of writing the orders out completely, overall 60.5% of the times nurses were pulled between teams. Third reason, overall 45.3% of the times the errors were associated with pharmacy when they did not prepare\label the medication correctly, and clinical pharmacist did not give education workshops to the nurses. Documentation issues were the fourth reason, 39.5% of the times nurses were interrupted while administering medication to perform other duties and nurses on the same unit did not adhere to the approved medication administration procedure. Conclusion: The data of the current study suggested the ranking of five reasons or root causes of why medication errors happened. These are medication package, system related, pharmacy related, documentation-transcription reason and physician-nurse related respectively. Furthermore, clinical pharmacists must thrive to improve the nurses' knowledge of how these factors will lead to critical errors and help them discover strategies to prevent these errors from happening.

scholarly journals Medication Administration Errors and Contributing Factors at Nurses Workplace: Literature Review

2021 ◽  
Vol 2 (10 (298)) ◽  
pp. 1-10
Author(s):  
Dovilė Sakalauskaitė ◽  
Viktorija Kielė
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Work Environment ◽  
Medication Errors ◽  
Human Factor ◽  
Medication Administration ◽  
Medical Team ◽  
Contributing Factors ◽  
Medication Administration Errors ◽  
Administration Time

Abstract. Medication errors are a serious problem that can be a threat to health and patient safety and can lead to mistrust of the health system and the work of professionals. Medication administration errors occur at any stage of patient care and can be related to a variety of influencing factors [1]. This literature review identifies the main medication administration errors, which are grouped into medication administration and incorrect documentation of administered medication groups. Along with medication administration errors, the main reasons why nurses make errors in medication administration are identified. The study focuses on medication administration errors and their determinants in nurses' work. The aim of the literature review was to analyze medication errors and their determinants in nurses' work. Methods: an exploratory review was conducted to analyze medication administration errors and their determinants in nurses' work. The methodology considered five main stages that contributed to a focused analysis of the selected studies. Results of the literature review. It was found that medication errors are influenced by the work environment, which is full of extraneous sounds, other members of the medical team, and conversations unrelated to the administration of medicines. The human factor is also a factor in medication administration errors related to the medication, its dose, or the wrong administration time. Medication administration errors are inevitable, no matter how advanced the patient's care and nursing techniques.

Medication-Related Errors: A Literature Review of Incidence and Antecedents

2006 ◽  
Vol 24 (1) ◽  
pp. 19-38 ◽  
Author(s):  
Gaya Carlton ◽  
Mary A. Blegen
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Current Literature ◽  
Associated Factors ◽  
Medication Administration ◽  
Medication Administration Errors ◽  
Individual Knowledge ◽  
Design Deficiencies

Patient safety has become a major concern for both society and policymakers. Since nurses are intimately involved in the delivery of medications and are ultimately responsible during the medication administration phase, it is important for nursing to understand factors contributing to medication administration errors. The purpose of this chapter is to identify the incidence of these errors and the associated factors in an attempt to better understand the problem and lessen future error occurrence. Literature review revealed both active failures and latent conditions established in Reason’s theory remain prevalent in current literature where active failures often display themselves in the form of incorrect drug calculations, lack of individual knowledge, and failure to follow established protocol. Latent conditions are evidenced as time pressures, fatigue, understaffing, inexperience, design deficiencies, and inadequate equipment and may lie dormant within a system until combined with active failures to create opportunity for error. Although medication error research has shifted in emphasis toward identification of system problems inherent in error occurrence, no one force emerges as a clear antecedent, reinforcing the need for further research and replication of existing studies with emphasis placed on more dependable reporting measures through which nurses are not threatened by reprisal.

scholarly journals Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Agani Afaya ◽  
Kennedy Diema Konlan ◽  
Hyunok Kim Do
Keyword(s):  
Medication Error ◽  
Hospital Setting ◽  
Medication Administration ◽  
Integrative Review ◽  
Medication Administration Error ◽  
Medication Administration Errors ◽  
Inadequate Knowledge ◽  
Administration Error ◽  
Uniform Definition ◽  
Definition Of

Abstract Background The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative. Objective This review systematically identified and examined the barriers hindering nurses from reporting medication administration errors in the hospital setting. Design An integrative review. Review methods PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication administration error reporting from January 2016 to December 2020. Two reviewers (AA, and KDK) independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018. Results Of the 10, 929 articles retrieved, 14 studies were included in this study. The main themes and subthemes identified as barriers to reporting medication administration errors after the integration of results from qualitative and quantitative studies were: organisational barriers (inadequate reporting systems, management behaviour, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons, and inadequate knowledge of errors). Conclusion Providing an enabling environment void of punitive measures and blame culture is imperious for nurses to report medication administration errors. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses’ ability to report medication administration errors.

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